Survey Readiness: Post-Acute Care Compliance Checkup

Federal and state agencies’ routine surveys of healthcare organizations can be stressful. As a post-acute care provider, you need to prove that your organization meets the expected standard of care, safety, and other compliance and regulatory requirements. Whether your focus is skilled nursing, home health, hospice, or another post-acute sector, are you confident in your survey readiness?

With the Biden administration advocating for stricter scrutiny on nursing homes, we know inspection of healthcare facilities may increase even more. Recently, the Centers for Medicare and Medicaid Services’ (CMS) Special Focus Facility Program report listed nursing homes that have not met the CMS’ health care or fire safety standards. Most of the inspected facilities had about six or seven deficiencies per inspection, some had more problems than the others, and some showed “a pattern of serious problems that had persisted over a long period of time.”

Regardless of the healthcare setting, you don’t want to be on this type of list. That would be terrible for your reputation and would hurt your business. Training your staff for competencies and compliance is crucial to minimizing deficiencies and increasing your chances of passing regulatory scrutiny successfully.

To ensure your survey readiness, it is essential to review the basics first:

• Align your protocols and procedures with federal and state regulations.
• Review your quality rating.
• Analyze the data to identify performance gaps.
• Train your staff to ensure competence and organization compliance.

What are surveyors looking for?

Quality of care and the environment of care that your organization provides are most important for surveyors. They will scrutinize your practices and procedures in many areas, including:

• Safety of the healthcare setting
• Staff training and licenses
• Quality care and optimal clinical outcomes
• Respectful communication and appropriate behavior
• Patient or resident satisfaction

Think like a surveyor

The surveyor will look for deficiencies in your organization and how your processes are inadequate. Try to identify those blind spots and work to fix them before the surveyor comes.

“Conducting routine audits of your organization’s practices and procedures, including auditing your coding and billing, may alert your leaders to some gaps in knowledge or the need for a quality initiative,” said Tameka N. Warren, MSN, RN, CLC, a home health writer for Relias. “Helping your staff find a problem before the surveyor does is extremely valuable.”

Some critical steps in survey readiness include:

• Recognize common deficiencies cited in your type of care setting
• Audit coding and billing to ensure clinical documentation integrity
• Assess your quality measure ratings, looking at benchmarks and trends
• Provide staff compliance and competency education, addressing any quality measure deficiencies
• Ensure training includes patient or resident assessments, organization processes, and care protocols

Analyze your survey readiness

Once you get the big picture, it’s time to analyze your survey readiness and identify gaps. Start with self-assessments and then conduct mock surveys with an external partner who will play the surveyor role.

You might find it helpful to walk around and view your business from a patient’s or resident’s perspective. Try to identify any safety concerns, look at the quality of services your staff provides, and ask your patients, residents, or clients for feedback on their satisfaction. Check your staffing status — Do you have the required patient-clinician ratio?

Check out the Relias Post-Acute Care Survey Survival Guide for a presurvey checklist to help analyze your organization.

Review your documentation

Now that you understand your current state, it’s time to focus on data and reporting, which must line up with federal and state requirements. For example, check that you have documentation on staff compliance, competence, and licenses. You should keep all the documentation needed for surveys in readily accessible yet secure folders, whether paper or digital.

Review your paperwork and document your QAPI activities. Your reports should reflect common issues, like falls or hospital readmissions, and those that might spur complaints, like pressure injuries. Document any resulting policy changes or revised safety measures.

Ensure that your leaders and team members are ready to respond to surveyors’ questions. For example, they need to know where to find resources related to clinical needs, patient or resident rights, policies and procedures, safety, and so on, and whom to contact in the organization when issues arise.

Maintain staff competency

The surveyor will check how well your team members are trained, and if they have the competencies they need to perform their roles. Keep your competency training up-to-date and relevant. If your staff has any related gaps in knowledge and skills, provide them with the education programs they need.

Make sure you know your current state so you can take steps to improve your survey readiness. With careful attention to these basics, you will be prepared when the surveyor comes calling.